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  • They even incorporated Recruitment maneuvers into
  • Ventilating Rats

Lung protective strategies   grooms Lung protective strategies grooms Presentation Transcript

  • Lung Protective Strategies: The Effects of Vt, PEEP & Alveolar Recruitment David Grooms BS, RRT Sentara Norfolk General, Leigh & Bayside Hospitals
  • Understanding ARDS……. 2 Types
    • Extrapulmonary ARDS (In-direct)
    • Pulmonary ARDS (Direct)
  • Identifying ARDS…….2 Types?
    • Pulmonary ARDS (Direct)
    • Pneumonia: Bacterial or Viral
    • Inhalation of noxious agent
    • Aspiration of Gastric Contents
    • Isolated pulmonary contusion
    • Fat Embolus syndrome
    • Extrapulmonary ARDS (In-direct)
    • Multi-system Trauma
    • Transfusion related ALI
    • Acute pancreatitis
    • Sepsis
    • Post- CABG surgery
    • Hemorrahagic shock
    Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4
  • Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158
  • Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Response to PEEP Recruitment Potential Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
  • Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158
  • Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Response to PEEP Recruitment Potential Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
  • Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158
  • Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20 cm) Response to PEEP High Recruitment Potential Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
  • Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158
  • Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20cm) Response to PEEP High Recruitment Potential Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
  • Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158
  • Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20cm) Response to PEEP High Recruitment Potential High Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
  • Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158
  • ARDS CT and PV Curve (slow inflation) # 6 -10 0 10
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  • Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20cm) Response to PEEP Low High Recruitment Potential High Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
  • Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158
  • Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Good (8-12cm) Excellent (10-20cm) Response to PEEP Low High Recruitment Potential High Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
  • Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158
  • Effects of Mechanical/Physical Stretch on Rat Alveolar Epithelial Cells
    • Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000
    • Excised Rat lungs
    • Placed Alveolar Epithelial Cells in a “cell-stretching device”
  • Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000
  • Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000 Both static and single deformations were significantly less injurious than cyclic deformations at each deformation level
  • Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000 Reducing the amplitude reduced cell death Cell Death dependent on frequency
  • ARDS Network
  • ARDS Network
    • Multicenter, Randomized trial
    • 861 Patients recruited from March 1996 through March 1999 at 10 university centers.
    • Patients enrolled if:
    • 1) They were receiving mechanical ventilation
    • 2) Had acute decrease in the P/F ratio (<300)
    • 3) Bilateral pulmonary infiltrates on a chest radiograph consistent with the presence of edema
    • 4) No clinical evidence of left atrial hypertension or if measure a PCWP<18mmHg .
  •  
  • Results
    • Trial was stopped after fourth interim analysis.
    • Mortality rates
      • 12 cc/Kg VT group- 39.8%
      • 6cc/Kg Vt group- 31.0%
      • Mortality decreased by 22%
    • Vt & Plat were significantly lower
    • Question to you-
    • What group had better PaO2’s?
    • 12 & they died more often- so better PaO2 does not translate into better outcomes
  • What did we do then?
    • We were skeptical at the results. Didn’t like it because Vt was so low.
    • Also questioned that mortality could have been better if more PEEP was used or use of Recruitment Maneuvers.
    • Did we interpret the results of the studies right???
  • Lower PEEP/Higher FiO 2 FiO 2 .3 .4 .4 .5 .5 .6 .7 .7 .7 .8 .9 .9 .9 1.0 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24 Higher PEEP/Lower FiO 2 FiO 2 .3 .3 .4 .4 .5 .5 .5-.8 .8 .9 1.0 PEEP 12 14 14 16 16 18 20 22 22 22-24 Target enrollment- 750 ALI, ARDS pts.
  • Recruitment Maneuver Attempts
    • RM’s were performed on the first 80 patients assigned to the higher PEEP group.
    • 1 or 2 manuevers per day @ 35-40cmH2O for 30 seconds.
    • Mean increase in O2sat was “small & transient.” Therefore RM were DC’d for the remainder of the trial.
  • Results
    • Trial stopped @ the 2 nd interim analysis after 549 pts. Had been enrolled.
    • Stopped based on the specified futility stopping rule.
    • Surprising Results
    ESSENTIALLY NO DIFFERENCE IN OUTCOMES (MORTALITY)
  • Interpretation…..
    • PEEP does not improve mortality of ARDS patients.
    • Added to our own confusion
    • Now what do we do if PEEP doesn’t help survival
    • Instead of developing my own interpretation of the results, I will wait around until someone shows me the right way to do it.
    • Do our dirty work for us!!!
  • So what can we do to try to do it right??
    • Question aspects of personal satisfaction vs. patient overall satisfaction
    VS I got the PaO2 up from 70-80 by turning the Vt up to 1200cc. You know I am the man right? Wow, awesome job, I will try to get it higher than you did today! You are the man
  • So what can we do to try to do it right??
    • Example: Patient with ALI/ARDS
    • Steps to take to minimize progression of syndrome
    • Minimize FIO2, make all attempts to decrease FIO2 < 60%.
  • Oxygen Dissociation Curve ARDSnet Study 88-94% PaO2 55-80
  • So what can we do to try to do it right??
    • Example: Patient with ALI/ARDS
    • Steps to minimize progression of disease/syndrome
    • Minimize FIO2, make all attempts to decrease FIO2 < 60%.
    • Management and consideration of Vt
  • Can mechanical ventilation actually produce lung injury?
    • Webb & Tierney, 1974, Am Rev Respir Dis 110:556-565
  • Key Findings of the study
    • Healthy Lungs with low PIP does not cause lung injury
    • Ventilation with high PIP (30-45) & no PEEP produces perivascular edema & leads to severe injury.
    • PEEP provides protection from alveolar edema due to high PIP.
    • Webb & Tierney, 1974, Am Rev Respir Dis
    • 110:556-565
  • Overdistention/Increased Transalveolar Pressure of Good alveoli Nieman, G
  • Take Home
    • Minimize Stretching of Healthy Alveoli by reducing Vt or Plat pressure.
    • OK but what about patients that do not have ALI/ARDS??
  • Crit Care Med 2004 Vol. 32, No. 9
  • Results
    • VT’s above 9cc/Kg cause VILI in non- ARDS patients.
    • The incidence of
    • VILI is higher in pts.
    • who get >9cc/Kg
    • VT. & blood transfusions.
    What if I go too low on the Vt because I am trying to protect?
  • Pt. Switched To AVTS Mode. Maintained @ 8-9cc’s/Kg Pt. Placed on 6cc/Kg Vt Pt. Placed on 8-9cc/Kg Vt Pt. Placed on 6cc/Kg Vt SNGH Burn/Trauma Unit
  • So what can we do to try to do it right??
    • Example: Patient with ALI/ARDS
    • Steps to take to minimize progression of syndrome
    • Minimize FIO2, make all attempts to decrease FIO2 < 60%.
    • Management and consideration of Vt
    • Management of PEEP
  • How to set PEEP
    • Use PEEP FIO2 table from ARDSnet study
    • FiO2 .3 .4 .4 .5 .5 .6 .7 .7 .7 .8 .9 .9 .9 1.0
    • PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24
    • This table is designed to be appropriate for the average patient, but sometimes PEEP needs to be individualized
  • How to set PEEP
    • Use PEEP FIO2 table from ARDSnet study
    • Set PEEP based off Lower Inflection point (pflex)
  • Rimensberger P et al. CCM 1999;27:1940-1945
  • Crit Care Med 2006 Vol. 34, No. 5
  • Villar, et al. Crit Care Med 2006 Vol. 34, No. 5 Amato, M. et al. 1998. NEJM
  • Minimizing Atelectatictrauma (repeated opening and closing) Nieman, G.
  • How to manage PEEP
    • Use PEEP FIO2 table from ARDSnet study
    • Set PEEP based off Lower Inflection point (pflex) +1-2cm
    • Set PEEP based off Point of maximum Curvature or recruitable lung volume via deflation limb of PV curve
  • The Effects of Recruitment on End-expiratory Lung Volume Barbas CSV Am J Respir Crit Care Med 2002;165:A218 APRV/HFOV puts pt. at this point
        • Hickling K. AJRCCM 2001;163:69-78.
    APRV/HFOV puts pt. at this point
  • Rimensberger P et al. CCM 1999;27:1940-1945
  • +350 cc’s
  •  
  • Maximizing a current modality
    • Not how much but HOW!
    • Pressure Modes: Use of Flow Time pattern for adequate inspiratory phase to improve gas distribution and minimize level of pressure needed for ventilation
  • I-times in Pressure Modes for Full Flow deceleration improve gas distribution and minimize PC level F T P T MAP MAP Vt Vt
  • I-times in Pressure Modes for Full Flow deceleration improve gas distribution and minimize PC level F T P T MAP Vt Vt
  • I-times in Pressure Modes for Full Flow deceleration improve gas distribution and minimize PC level F T P T MAP Vt Min.Insp. Pressure Adjustments Needed Vt Vt
  • Maximizing a current or alternative modality
    • Not how much but HOW!
    • Pressure Modes: Use of Flow Time pattern for adequate inspiratory phase to improve gas distribution and minimize level of pressure needed for ventilation
    • Use of Airway Pressure Release Ventilation (APRV), HFOV, Jet Ventilation
  • Normal Ventilation with Normal MAP P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15
  • Increase in Insp. Pressure What will happen to MAP? P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 25
  • Increase in Insp. Pressure What will happen to Plat ? P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 25
  • Increase in PEEP, What will happen to MAP & Plat? P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 10
  • APRV (Basically inverse Ratio with Spont. Breathing during insp. Phase.) Can Increase MAP and keep safe Plat. & spont. Breath. P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 = If Flow is Fully dec. Spontaneous Breaths
  •  
  • Summary
    • Understand disease type, what is cause for inflammation of the Lung
    • Manage FIO2 < 60% with PaO2 > 60mmHg & SpO2 > 88%
    • Manage Vt (4-8cc/KgIBW) & Plateau Pressure < 30cmH2O to minimize stretch on good and bad alveoli. >9cc/Kg IBW in non ARDS patients increases incidence of ALI developement
    • Commericial Vents actually incorporate an automatic Lung Protective Strategy (Hamilton Galileo/ASV Mode & Drager Evita XL)
  • Summary
    • PEEP can be managed by multiple options, Goal is to prevent repeated alveolar opening and closing, and proper recruitment of dependent lung units
    • Alternative Modes can improve specific indices, but lack appropriate randomized clinical trials for universal acceptance
    • Optimize settings to improve gas distribution on conventional modes
  • Thank Y’all for having me!!